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Mary Lynn Everson, MS, LCPC Senior Director, Marjorie Kovler Center Martin Hill, PhD

Indicators Likely to Contribute to Treatment Success Among Survivors of Torture: Heartland Alliance Marjorie Kovler Center. Mary Lynn Everson, MS, LCPC Senior Director, Marjorie Kovler Center Martin Hill, PhD Associate Director, Research and Evaluation, Marjorie Kovler Center

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Mary Lynn Everson, MS, LCPC Senior Director, Marjorie Kovler Center Martin Hill, PhD

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  1. Indicators Likely to Contribute to Treatment Success Among Survivors of Torture: Heartland Alliance Marjorie Kovler Center Mary Lynn Everson, MS, LCPC Senior Director, Marjorie Kovler Center Martin Hill, PhD Associate Director, Research and Evaluation, Marjorie Kovler Center December 5, 2016

  2. Who we are… • Torture treatment center located in Chicago Illinois providing comprehensive services for 30 years • Program of Heartland Alliance International with human rights programs in 12 countries • Subsidiary of Heartland Alliance for Human Needs & Human Rights advancing the human rights and responding to the human needs of endangered populations for 128 years

  3. Heartland Alliance Marjorie Kovler Center Mission Marjorie Kovler Center helps transform the lives of individuals recovering from the complex consequences of torture. Kovler Center provides medical, mental health, and social services; trains and educates locally and globally; and advocates for the end of torture worldwide.

  4. Snapshot: Marjorie Kovler Center • Established in 1987 • Serve 350-380 annually; 75-90 new participants annually • 60 countries represented annually • Majority seeking asylum • Staff of 16 full-time, part-time & contractual (9.88 FTE) • 200 pro bono professionals and para-professionals

  5. Heartland Alliance Marjorie Kovler Center

  6. Community-based Torture treatment is best supported in a community context Building free-standing and located in a residential neighborhood Services offered on-site and in private offices by staff and/or volunteers Volunteer-based Torture breaks the bonds of the individual with family and community – community needs to be involved in the response Extend services to large number of survivors by engaging a wide range of volunteers (200) No cost Long standing commitment to ensuring survivors do not pay for rehabilitation

  7. Holistic approach to integrated services - medical, mental health, social and access to legal services as coordinated by staff Trauma-informed approach that is empowerment-focused, strength-based and survivor-driven Supporting spiritual well-being • Culturally and linguistically sensitive services – make adaptations, respect traditions, understand context, provide interpretation and translation • Rebuilding community- break isolation, overcome helplessness, connect with strengths and resilience • Access to justice – asylum process, indict perpetrators, and reparations

  8. Three stages of recovery • Establishment of safety • Remembrance and Mourning • Reconnection with Community

  9. Staff and volunteers – trauma-informed approach Eclectic, choosing different approaches for different participants Psychodynamic, informed by relational psychoanalytic theory Family systems theory Narrative therapy Somatic therapy Existential therapy Cognitive behavioral therapy Psychoeducation Mindfulness

  10. 377 individuals; 80 new 61 countries 85% primary survivors, 15% secondary survivors 54% male and 46% female 89% were between 18-64 years old 70% were from Africa Top countries new participants: Congo, Togo, DRC, Cameroon and Rwanda Survivors Served in FY 2016 • 244 participants received medical or rehabilitative services • 218 received mental health services • 317 received case management or social services • 10,919 hours provided pro bono valued at ~$436,620 • 30 data points drawn from EHRS

  11. History of outcome evaluation • Hopkins Symptom Checklist • Harvard Trauma Questionnaire • A variety of other outcome tools, none satisfactory

  12. Development of Marjorie Kovler Center Well-being Questionnaire • Addressed participant objectives/needs • Addressed staff objectives • Consultation with evaluation expert • Developed functional assessment tool • Piloted in 2009

  13. Outcomes in multiple domains – MKC Well-being Questionnaire • Immigration Status • Physical Health • Employment/Education/Training • Housing • Language • Personal Relationship • Satisfaction with services

  14. HSCL anxiety, depression, and total scores are all markedly lower at each 6-month follow-up compared to intake. All three scores show a slight increase from 18 to 24 months out. Hopkins Symptoms Checklist-25 (HSCL) Scores Over Time (Mean Score)

  15. Over time, the proportion of MKC participants who are symptomatic for anxiety and depression decreases noticeably. Interestingly, this proportion increases slightly from 18 to 24 months. Hopkins Symptoms Checklist-25 (HSCL) Total Scores Over Time (% Symptomatic)

  16. HTQ DSM-IV and total scores are also much better at each 6-month interval compared to intake and plateau at the 18-month mark. Harvard Trauma Questionnaire (HTQ-R) Scores Over Time (Mean Score)

  17. Similarly, the proportion of MKC participants who are symptomatic for PTSD decreases significantly from 50.6% at intake to 16.9% at 18 months, then rises to 23.1% at 24 months. Harvard Trauma Questionnaire (HTQ-R) Scores Over Time (% Symptomatic)

  18. The proportion who have authorization to work increases steadily over time. One-fourth (25.9%) of participants are authorized to work at intake, compared to 78.5% at 24 months. Have Work Authorization Over Time (% Yes) n=243 n=166 n=139 n=138 n=130

  19. MKC participants find employment over the course of their treatment plan. At intake, only 17.5% are employed but by 24 months 66.3% are employed, with 48.4% of them employed full-time. Employment Status Over Time 66.3% 17.5% n=240 n=165 n=137 n=138 n=128

  20. More MKC participants attend school/takes classes after intake, especially during the first year. The vast majority take ESL classes to improve their English skills. In School/Taking Classes Over Time (% Yes) n=242 n=166 n=139 n=138 n=130

  21. MKC participants’ use of the English language improves slightly over time, however, the improvement is seen more in the ability to read and write English. For example, 65.2% could read English at least somewhat well at intake, compared to 75.2% at 24 months. English Language Fluency Over Time (% Somewhat Well/Very Well) n=230 n=161 n=137 n=138 n=128

  22. Legal status eventually improves for all MKC clients. For example, at 24 months participants are have either applied for asylum, been granted asylum, or become a legal permanent resident. Legal Status Over Time 37.7% 39.3% 7.0% n=243 n=165 n=139 n=138 n=130

  23. Housing status also improves for program participants over time. Upon intake, very few clients pay rent toward their housing, however, by 24 months almost eight in ten pay rent. Housing Status Over Time 79.9% 24.2% n=243 n=166 n=138 n=137 n=129

  24. The program also has an impact on clients’ personal relationships. Clients’ satisfaction with how they interact and get along with friends and family improves notably beyond intake. Satisfaction with Interpersonal Relationships Over Time (% Somewhat Satisfied/Very Satisfied) n=212 n= 149 n=126 n= 129 n= 124

  25. Participants who experience a variety of chronic pain/conditions upon entering the program generally see these ailments dissipate over time. This is especially true for migraine headaches, racing heartbeat, night sweats, and digestive problems. Chronic Conditions/Physical Pain

  26. Among those participants who completed a 24-month re-administration, 60.6% are male and 39.4% are female. Almost half (48.0%) were between the ages of 25 and 34 at intake and the average age at intake was 33 years. Gender and Age (Among Those Who Competed a 24-Month Re-administration) Gender Age 18 to 24 25 to 34 Male, 60.6% Female, 39.4% 35 to 44 45 or Older (n=127) (n=127) Mean Age = 33.2

  27. Three-fourths of the participants who completed a 24-month re-administration are from one of twenty-one African countries, while 11.8% represent two European countries and 9.4% represent nine Asian countries. Country and Region (Among Those Who Competed a 24-Month Re-administration) • Guatemala • Angola • Benin • Burundi • Cameroon • Central African Republic • Chad • Congo • Cote D’Ivoire • DRC • Egypt • Egypt • Ethiopia • Gabon • Guinea • Nigeria • Rwanda • Senegal • Somali • Sudan • Togo • Uganda Americas, 3.1% • Bhutan • China • Iraq • Kazakhstan • Kyrgyzstan • Mongolia • Russian Federation • Sri Lanka • Turkey Asia, 9.4% Africa, 75.6% Europe, 11.8% (n=127) • Bosnia • Moldova

  28. Paired sample t-tests were used to examine changes in participants scores on the HSCL and HTQ instruments. The mean level of distress decreases significantly from intake to 24-month re-administration. Cohen’s d, which measures effect size, further indicates the strength of the change between intake and 24-months. Change in Clinical Measures Between Intake and 24-Month Re-Assessment

  29. Partial correlations demonstrate significant relationships between HSCL anxiety, depression, and total at 24 months with regard to (1) region, (2) whether or not participants required an interpreter while in the program, and most significantly with regard to (3) whether or not they had a secure legal status while in the program (e.g., granted asylum, legal permanent resident), while controlling for intake HSCL scores. There was also a significant relationship between participants’ secure legal status and HTQ total scores at 24 months (also controlling for HTQ intake scores). Associations Between Predictors Variables and Distress at 24-Months Controlling for Baseline Distress (n=89)

  30. The strongest predictors of clinical improvement for anxiety are obtaining legal authorization to stay in the U.S. (e.g., obtaining asylum, legal permanent resident) and whether or not the participant requires interpretation. Generalized Linear Model Predicting Improvements on the HSCL Anxiety Subscales (n=102)

  31. The strongest predictors of clinical improvement for depression are obtaining legal authorization to stay in the U.S. and region, specifically being of European origin. Generalized Linear Model Predicting Improvements on the HSCL Depression Subscale (n=102)

  32. The strongest predictor of clinical improvement for both anxiety and depression (HSCL total) is obtaining legal authorization to stay in the U.S. Generalized Linear Model Predicting Improvements on the HSCL Total Scale (n=102)

  33. Looking at the HTQ total scale, the strongest predictors of clinical improvement for PTSD are obtaining legal authorization to stay in the U.S. and region, specifically being of Asian origin. Generalized Linear Model Predicting Improvements on the HTQ Total Scale (n=102)

  34. Study Strengths and Limitations • Multiple time points assessing change over time • Ability to assess trends over time (24-month interval) • Small sample size (n=127) • Lack of control group or comparison (quasi control) group

  35. Summary • Demographic variables, with the exception of region, are not predictors of clinical improvement, whereas program-related variables are significant predictors of change over time • Predictors of clinical improvement, such as requiring an interpreter and obtaining legal authorization to stay in the US, are significant predictors that should be incorporated into future treatment programs

  36. Participants are greatly satisfied with the Kovler Center overall, rating it a 3.86 on a 4-point scale. They especially like the staff members, who they consider to be polite, respectful, and empathetic. An area of opportunity for MKC is to find better ways to connect participants to community resources. Satisfaction With Aspects of Kovler Center (0-4 Scale) The services offered at the program are relevant to my needs Overall satisfaction with the Kovler Center Staff and volunteers are polite and respectful Staff responds to my needs in a timely fashion Staff and volunteers listen to me and understand me The program helps me cope successfully with my challenges I am encouraged to participate in my treatment planning The program embraces my culture and language The Kovler Center is pleasant, clean, and comfortable The program helps me obtain community resources (n=435) Please rate the following on a scale of 1 to 4, where 1 means “not at all,” 2 means “a little,” 3 means “quite a bit,” and 4 means “very much.”

  37. When participants are asked to report (top of mind) the things that have been the most helpful to them, their responses are wide ranging. This indicates that MKC provides a number of services that clients consider helpful. That said, it is clear that participants find medical assistance and therapymost helpful. They also appreciate the professional and caring staff and all the assistance they provide with getting asylum, transportation, dental care, legal aid, and food. One in five report “everything” about MKC has been good or helpful. Kovler Services Clients Find Most Helpful* Medical assistance/medical care/medication Food assistance Kovler events (e.g., cooking group, field trips) Therapy/psychotherapy/ psychiatric services Everything has been helpful Case Managers/Management Gives hope/turns life around/ rehabilitate life Assistance to their children Asylum support/help with their case/legal status Assistance with papers/ documentation Professional/caring/friendly/ responsive staff Kovler is like family/home Counseling/advice Employment assistance Legal assistance Clothing assistance Transportation assistance Eye exam/vision assistance Dental assistance Housing assistance (n=435) What are some things about Kovler Center that have been the most helpful to you? (Multiple responses allowed) *Only responses greater than 2% shown.

  38. Verbatim Comments – Positive “The way the staff work here, they received me as if I were family. The staff are very attentive to our needs and understand everything you need in the time you need it.” “Helped me feel more comfortable. Kovler did a lot for me. When I am here it's like I'm in Africa. I’m comfortable and calm here.” “Kovler is like my family, it's like the parent and we are all the children (how parents help children). Therapy has been very helpful, medical assistance very good.” “Feels like a family, respectful and kind staff. Very warm and inviting atmosphere (asks if I want coffee/teat/water). Very sensitive. Found translator for me.” "Kovler is my only home in the US. It gives me a home. It made me realize everyone has a second chance. It gave me a new life. Kovler gave me back my life.“ “Every person has been helpful. It was like I was in a storm and then saw sunshine again. Medical assistance, therapy.” “Everything, all the services. I’ve never been treated with respect like I have here at Kovler. It is a miracle and I feel like I'm going to Heaven when I come here. It lifts my morale and makes me happy about the future.“ "Without Kovler I don't know what would have become of me. They did everything for me. Exceedingly serviceable for us. Gave us place to stay/shelter, the therapy, medical assistance, asylum assistance.” “I'm not sure I could survive in this country if I hadn't found Kovler. They helped me with everything; insurance, my leg was badly beaten and Mary T. fixed it and now I can walk and stand without pain.”

  39. Because of their previous life situation and their satisfaction with MKC’s services, three in five (60.9%) of the participants are unable to offer any criticism or suggestions for improvement. Those who do would like to see better follow through on appointments/plans, better assistance with housing and employment issues, shorter wait times for services, and better assistance with medical issues. Suggestions for Improvement at MKC Better assistance with documentation/asylum process Nothing/Can’t think of anything Better follow-up/follow through (e.g., appointments, plans) Shorter wait time to see doctors Better housing assistance More resources to help more people Better assistance in finding employment/jobs Cleaner/spruced-up/ newer looking Shorter wait time to see Kovler staff Less staff turnover More/better assistance with medical issues Better assistance with education/ESL/English Transportation assistance More food assistance Have another location closer to where clients live Other (n=435) What are some things about Kovler Center that could be improved? (Multiple responses allowed)

  40. Verbatim Comments – Opportunities for Improvement “Too much turnover, especially among Case Managers. You get used to working with certain staff and then they leave. Additionally, the new CM's aren't as experienced and don't seem to know my case as well as the previous Case Managers.” “Had to wait too long to get initial treatment (2 months). Talked to [one CM] first, then 2 months went by before Mario did assessment.” “Reduced wait times to see doctors, it's currently too long. Help with legal assistance, would be ideal of legal person was onsite. Better help in finding housing, help in moving.” “The biggest area that could use support - and I see this among clients in need - is helping people find work. This would help people's overall mental health and well-being, as well as help them earn money.” "More resources like Jewel cards, bus cards. It's very far for him to travel for two appointments a month.“ “Building looks bad and old, colors are bad and make people depressed. Case managers and therapists have to act more quickly.” “Sometimes there is miscommunication/misunderstanding between me and CM. For example, I’ve been calling urgently to get an appointment with an OB/GYN and they haven't helped me or contacted me about this yet. CM doesn't seem to have the same sense of urgency as me.” “Could have provided better help with the asylum process. It was stressful and any mistakes made make the whole process take longer. Kovler could oversee it to limit mistakes.” "Music services here, would like to play instruments (therapy for adults), gym center or place to do exercises here, sports groups (soccer or basketball).”

  41. Contact Information Mary Lynn Everson, MC, LCPC, Senior Director, Marjorie Kovler Center meverson@heartlandalliance.org 224 479-2701 (office) 312 735-6068 (cell) @MaryLynnEverson (twitter) Martin Hill, PhD Associate Director, Research and Evaluation mhill@heartlandalliance.org 224 479-2713(office) 847 785-9877 (cell) 1331 West Albion Avenue Chicago, IL 60626 www.kovlercenter.org www.facebook.com\kovlercenter

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